Buprenorphine can cause significant dental problems

[whopper]

Buprenorphine dissolved in the mouth can cause dental problems

Benefits for use outweigh these risks and oral care can help

www.fda.gov

I haven't seen an industry warning about this. I have, however, seen 2 patients that after being placed on Buprenorphine experienced significant dental problems. It may have been coincidence but when I saw the above it wasn't surprising.

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[littlefred]

Buprenorphine dissolved in the mouth can cause dental problems

Benefits for use outweigh these risks and oral care can help

www.fda.gov

I haven't seen an industry warning about this. I have, however, seen 2 patients that after being placed on Buprenorphine experienced significant dental problems. It may have been coincidence but when I saw the above it wasn't surprising.

Yay! more stigma about treatment of OUD.

I wonder if they removed the confounding factor of people that don't seek dental care vs those who actually did.

Guess what's not a priority when you have a use disorder? You guessed it. Poor dental care.

 

[Crayola227]

Yay! more stigma about treatment of OUD.

I wonder if they removed the confounding factor of people that don't seek dental care vs those who actually did.

Guess what's not a priority when you have a use disorder? You guessed it. Poor dental care.

Yeah, guess you missed the part where they said 26 of 28 patients had zero history of dental problems, and some of the issues started as soon as 2 weeks after starting the med. Could be coincidence, but it doesn't really support your theory that these are people with bad teeth.

It's ironic you bring up stigma while also furthering the idea that people with use disorders all have bad teeth or don't care for them. While there is certainly a link between mental health issues and poor hygiene, that isn't a rule and I would hope that anyone bringing up risks of bupe and oral health would consider that before concluding whether or not the drug poses a threat.

The issues led to extractions, and still said benefits outweighed risks. We're not just talking dry mouth or something, extractions are kind of a big deal. I mean, getting off opiods is probably worth your teeth, but man.

 

[littlefred]

Yeah, guess you missed the part where they said 26 of 28 patients had zero history of dental problems, and some of the issues started as soon as 2 weeks after starting the med. Could be coincidence, but it doesn't really support your theory that these are people with bad teeth.

It's ironic you bring up stigma while also furthering the idea that people with use disorders all have bad teeth or don't care for them. While there is certainly a link between mental health issues and poor hygiene, that isn't a rule and I would hope that anyone bringing up risks of bupe and oral health would consider that before concluding whether or not the drug poses a threat.

The issues led to extractions, and still said benefits outweighed risks. We're not just talking dry mouth or something, extractions are kind of a big deal. I mean, getting off opiods is probably worth your teeth, but man.

I did use a broad generalization but think about it, you have a patient that is seeking treatment for OUD and because of this they might not start treatment. It's the same principle with many of our psychotropic meds, because of a perceived possible damage we sometimes withhold treatment (prolonged QT for example).

What other options do you have?

A. Doing bupe for a week then sublocade? (very few clinics offer sublocade)
B. Send to methadone clinic? (some patients don't want methadone or the structure of an OTP)
C. Offer them Naltrexone? (some patients don't like the idea of having withdrawals even with comfort meds)
D. No treatment

 

[hallowmann]

I did use a broad generalization but think about it, you have a patient that is seeking treatment for OUD and because of this they might not start treatment. It's the same principle with many of our psychotropic meds, because of a perceived possible damage we sometimes withhold treatment (prolonged QT for example).

What other options do you have?

A. Doing bupe for a week then sublocade? (very few clinics offer sublocade)
B. Send to methadone clinic? (some patients don't want methadone or the structure of an OTP)
C. Offer them Naltrexone? (some patients don't like the idea of having withdrawals even with comfort meds)
D. No treatment

Isn't this just the definition of informed consent though? We've been telling people this for a bit and no one has declined care. You put it into context, recommend rinsing your mouth after, recommend regular dental care, etc.

This is the same as telling anyone that sexual side effects can happen with SSRIs. You warn about adverse effects, put into context the likelihood of it happening, and allow the patient to make the choice. Not doing so or concealing this information is a paternalistic act and a disservice to patients.

 

[calvnandhobbs68]

Isn't this just the definition of informed consent though? We've been telling people this for a bit and no one has declined care. You put it into context, recommend rinsing your mouth after, recommend regular dental care, etc.

This is the same as telling anyone that sexual side effects can happen with SSRIs. You warn about adverse effects, put into context the likelihood of it happening, and allow the patient to make the choice. Not doing so or concealing this information is a paternalistic act and a disservice to patients.

lol right I don't go to people "hey you might have sexual side effects with this SSRI, so I guess I'm not gonna prescribe it?" Its just making people aware this is a possible side effect, how to mitigate it and letting us know if it comes up. If someone truly did start having dental issues, than yeah referring them to somewhere that does sublocade could be a reasonable option.

 

[littlefred]

lol right I don't go to people "hey you might have sexual side effects with this SSRI, so I guess I'm not gonna prescribe it?" Its just making people aware this is a possible side effect, how to mitigate it and letting us know if it comes up. If someone truly did start having dental issues, than yeah referring them to somewhere that does sublocade could be a reasonable option.

All valid points, sexual side effects are probably the #1 reason young adults stop taking anti-depressants so discussing that is definitely important.
Hasn't stopped me from prescribing them though, and this teeth thing won't stop me from prescribing Suboxone.

I just see that in the big picture, if you will, this will bring down the numbers of patients starting suboxone... another "bump" on the road.

Other limitations on suboxone is patient limits, mandatory 8 hour course (that recently got waived) etc. (no such limitation on schedule II's though)

Just another little thing that makes suboxone less attractive for prescribers and patients which is no bueno.

 

[littlefred]

Isn't this just the definition of informed consent though? We've been telling people this for a bit and no one has declined care. You put it into context, recommend rinsing your mouth after, recommend regular dental care, etc.

This is the same as telling anyone that sexual side effects can happen with SSRIs. You warn about adverse effects, put into context the likelihood of it happening, and allow the patient to make the choice. Not doing so or concealing this information is a paternalistic act and a disservice to patients.

Now all of a sudden I'm being paternalistic and doing disservice to patients?

What?

We are talking about Suboxone here not SRI's.

I wonder how many of you guys are actually going into detail with the patients about all the side effects our medications have, signing consents and all that jazz.

And to add to my point above it was about some psychiatrists not prescribing dopamine antagonists if your QTc is above 450 ms, or not prescribing naltrexone if your AST/ALT are 3x above normal value. Maybe an extreme example, but I've seen it many times where they don't prescribe for those reasons (where clearly the benefits outweigh the risk, which is clearly also noted on the FDA warning for the teeth thing on bupe as well).

 

[calvnandhobbs68]

I wonder how many of you guys are actually going into detail with the patients about all the side effects our medications have, signing consents and all that jazz.

I have SSRI/SNRI, alpha-agonist, anticonvulsant, stimulant and antipsychotic consent forms that I have patients sign, especially for patients <18yo. But yes, certainly we can't go over every single side effect that's on the label of every medication, I think the FDA warning is more to make people aware that this could be a side effect to discuss with patients. I certainly wouldn't send someone to a methadone clinic just because they could get cavities.

 

[hallowmann]

Now all of a sudden I'm being paternalistic and doing disservice to patients?

What?

We are talking about Suboxone here not SRI's.

I wonder how many of you guys are actually going into detail with the patients about all the side effects our medications have, signing consents and all that jazz.

And to add to my point above it was about some psychiatrists not prescribing dopamine antagonists if your QTc is above 450 ms, or not prescribing naltrexone if your AST/ALT are 3x above normal value. Maybe an extreme example, but I've seen it many times where they don't prescribe for those reasons (where clearly the benefits outweigh the risk, which is clearly also noted on the FDA warning for the teeth thing on bupe as well).

I was not insulting you or saying that is what you are doing (you actually never said you don't tell patients about adverse effects), I was simply saying that informed consent is important, and we shouldn't just assume its "better" they not know about it. You took that a lot more personally than I expected.

I don't go into "all" side effects with patients, but I try to mention constipation, sweating, sedation, sleep disturbance, nausea, headaches, dry mouth, the taste, urinary hesitancy, and now dental considerations, with patients I start on it, and check on these with follow-up. If possible, I pull up UpToDate for the med, go to adverse effects, and show it to patients. Its not like a long conversation, I simply list potential things that can happen, and if they are worried about anything specific we talk more. Typically takes <1-2 min. No one I've seen has actually decided against taking Suboxone due to this discussion, and as you said benefits often outweigh risks.

I don't do written consents for individual meds/symptoms, because honestly I don't think they legally hold up and it seems like a bit of a waste of time, but I document what I talk about (its usually a dot phrase that I edit if I forget something). I know some psychiatrists that do, and it's based on their comfort level, but I doubt they're enforceable.

 

[ObsequiousAplomb]

I am curious about the dental damages of Suboxone. I wondered if there was some confound as mentioned above - going to the dentist isn't always a priority for younger adults to middle age, and it might not be a huge priority in people who have untreated substance or other mental health conditions.

If you haven't been to the dentist in 10+ years (here I'm thinking generally about 28-40 year olds, the people I'm most likely to be doing a Suboxone induction for), it would make sense that you don't have a record of dental problems. People who start treatment for Suboxone might be more inclined at that time to address their general health, and that includes seeing a dentist again. Even if they're going for an annual cleaning and they have been diligent, it's not unheard of for previously dentally healthy people to develop major dental problems.

I'm open to the suggestion that I'm inadvertently biased in this. Consciously, my thinking is related to me - I didn't see a dentist throughout college or medical school and only got to see one back when I started residency. 6/8 of the people in my class said the same thing. About half of them had major dental problems that previously they had no record of. I was under the impression when I thought this about the buprenorphine dental problems when I first read about them that there might be a similar confound, and I see that a part of my bias here is thinking that many Suboxone patients are in their late 20s to early 30s.

There's also potentially an inclination to take the Suboxone first thing upon awakening, and maybe leaving home for work before it's time enough to brush teeth, or at the end of the night and falling asleep before brushing and flossing.

 

[hallowmann]

I am curious about the dental damages of Suboxone. I wondered if there was some confound as mentioned above - going to the dentist isn't always a priority for younger adults to middle age, and it might not be a huge priority in people who have untreated substance or other mental health conditions.

If you haven't been to the dentist in 10+ years (here I'm thinking generally about 28-40 year olds, the people I'm most likely to be doing a Suboxone induction for), it would make sense that you don't have a record of dental problems. People who start treatment for Suboxone might be more inclined at that time to address their general health, and that includes seeing a dentist again. Even if they're going for an annual cleaning and they have been diligent, it's not unheard of for previously dentally healthy people to develop major dental problems.

I'm open to the suggestion that I'm inadvertently biased in this. Consciously, my thinking is related to me - I didn't see a dentist throughout college or medical school and only got to see one back when I started residency. 6/8 of the people in my class said the same thing. About half of them had major dental problems that previously they had no record of. I was under the impression when I thought this about the buprenorphine dental problems when I first read about them that there might be a similar confound, and I see that a part of my bias here is thinking that many Suboxone patients are in their late 20s to early 30s.

There's also potentially an inclination to take the Suboxone first thing upon awakening, and maybe leaving home for work before it's time enough to brush teeth, or at the end of the night and falling asleep before brushing and flossing.

Obviously there's probably some overlap, but there's individuals with no report of prior dental issues and then having severe issues after being on SL buprenorphine (not seen with Sublocade despite similar populations), so there is likely something else as well. Maybe it's something preservative related, maybe it's the buprenorphine, maybe it's people drinking a sugary drink every day after starting because of the taste, maybe it's actually the buprenorphine, but it does seem to happen.

 

[whopper]

It's hard to make judgments on the FDA's warning without seeing the data itself and I haven't. A pubmed search of "Buprenorphine dental" only brings up 1 article which is only showing the warning but no data. An Ecosia search engine brings up a case study with 2 people? WTF?

I'm going to throw in a bit of a conspiracist angle. Buprenorphine came out long before Suboxone and when it went generic the company comes out with Suboxone films and giving warnings that Buprenorphine can be liquified, injected and abused but now Suboxone gets rid of this problem so Suboxone must be given as if it's the only option. Obviously they wanted to keep onto the Suboxone goldmine. I still to this day see no serious reason to back Buprenorphine/Naloxone over regular Buprenorphine.

1-I've never seen one patient liquify Buprenorphine. The bottom line is abusers would rather use it to treat withdrawal so they can go back on work on Monday from a Friday night party. Further the street value of Buprenorphine was more expensive that heroin.
2-Suboxone's manufacturer is now making Sublocade. Did they want the FDA to push a dental scare tactic to avoid oral use?

You can accuse me of being street-dumb and naïve. I worked as a jail doctor and would catch patients trying to abuse pretty much everything. I was part of an effort to get Quetiapine pretty much almost never prescribed in jail. I avoided Quetiapine prescriptions in several because it had a street use of mixing it with stimulants to make a speedball or adding it to opioids to heighten the high.

I have seen people say Buprenorphine films did cause oral irritation so I just switched them to the tablets and that usually settled the issue, or vice-versa. But does it really cause significant dental problems? Show me the data. This is frustrating-to warn patients about something and not seeing the data for yourself.

Same thing happened with the QT prolongation with Escitalopram. The FDA gave out warnings but data wasn't brought out backing it for several months.

 

[smalltownpsych]

it is not exactly an out there conspiracy to think that drug companies who stand to make billions off medications that have a high level of physiological and psychological dependence might be putting pressure on the FDA. It’s not like that happened before with anything else, right?

Follow the money and connect the dots. Sales went from well over a billion a year to just over 500 million in 2019. Profits from 20 million to a loss of 42 million. They come up with a great idea for long acting injectable, but is that really needed when compliance is not really an issue? What are we going to do? Aha, we have this finding about cavities in our own internal company research and if we neglect all the confounds and get the FDA to scare people enough about it, then maybe we can make them buy this other product and bring back the happy days of big profits again.

What is sad is that they should still be able to get rich off selling suboxone even when a competing generic is available. If you can’t make money off addictive substances then you are a really lame drug dealer.

 

[hallowmann]

I've seen people have dental problems, and certainly complain of things like dry mouth which absolutely has a documented impact on risk for dental caries and other complications, but I've never actually seen a major dental complication clearly linked to Suboxone. I've also never seen TDP from Lexapro, but I still mention it to patients. I also believe there is an argument that the acidic nature of Suboxone, the frequency with which some people take it, and the duration of keeping it in your mouth long enough to dissolve is suspected to be the culprit. I certainly don't put it past the drug company to manipulate things, but I also don't think it means we just ignore something that could certainly be a (rare) effect.

I've seen people switch from Suboxone to Zubsolv to Subutex for any variety of reasons that mostly seem like individual preference, but I've never actually seen anyone switch to Sublocade because of anything other than 1) having trouble with stable/consistent SL adherence (both missing or taking extra), 2) the taste (seriously everyone hates it, this really can't be fixed?), 3) temporarily for travel, and 4) convenience or stigma. These are all very reasonable expectations and benefits of an LAI like Sublocade, so I would argue there is value in it.

 

[smalltownpsych]

I've seen people have dental problems, and certainly complain of things like dry mouth which absolutely has a documented impact on risk for dental caries and other complications, but I've never actually seen a major dental complication clearly linked to Suboxone. I've also never seen TDP from Lexapro, but I still mention it to patients. I also believe there is an argument that the acidic nature of Suboxone, the frequency with which some people take it, and the duration of keeping it in your mouth long enough to dissolve is suspected to be the culprit. I certainly don't put it past the drug company to manipulate things, but I also don't think it means we just ignore something that could certainly be a (rare) effect.

I've seen people switch from Suboxone to Zubsolv to Subutex for any variety of reasons that mostly seem like individual preference, but I've never actually seen anyone switch to Sublocade because of anything other than 1) having trouble with stable/consistent SL adherence (both missing or taking extra), 2) the taste (seriously everyone hates it, this really can't be fixed?), 3) temporarily for travel, and 4) convenience or stigma. These are all very reasonable expectations and benefits of an LAI like Sublocade, so I would argue there is value in it.

Everything you said is probably fairly accurate and well reasoned and these companies love to take that info and run with it until it bears little semblance to the truth because there is just way too much money involved. Not proposing a solution, just saying that as medical providers, we need to take this more into account and I don’t think we do a good job of that. Often, we feel like lone voices in the wilderness and powerless against the big powerful interests whether it is the pharmaceutical companies, insurance companies, or the federal government.

In short, some patients will likely benefit from suboxone or sublocade or just about any other medication and that is a good thing, but the company is always motivated to expand their market and eventually this leads to bad things.

 

[mistafab]

Giving a lot of suboxone scripts you’ll definitely hear patients frustrated by how it tears up their mouth.

Edit: It wasnt until recently that I started talking to patients about it in the r/b/se discussion. I felt bad that my bias made me think “they’re just making it up so they can get pure bup” like a jackass until I heard about the FDA thing in January.

 

[littlefred]

Giving a lot of suboxone scripts you’ll definitely hear patients frustrated by how it tears up their mouth.

Edit: It wasnt until recently that I started talking to patients about it in the r/b/se discussion. I felt bad that my bias made me think “they’re just making it up so they can get pure bup” like a jackass until I heard about the FDA thing in January.

Looks like it's any orally dissolving buprenorphine, including Subutex. There were some case also with Belbuca which is another vehicle and not done sublingually, but still inside the oral cavity.